Healthcare Provider Details

I. General information

NPI: 1245854165
Provider Name (Legal Business Name): SAMANTHA DASTRUP AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

IV. Provider business mailing address

1631 SE SALMONBERRY AVE
DALLAS OR
97338-1989
US

V. Phone/Fax

Practice location:
  • Phone: 719-343-5809
  • Fax:
Mailing address:
  • Phone: 719-342-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number242012
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number61302790
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP500339167
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95038256
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10007031
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: